9601-122 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is iniull force and effect.
License # Lic. Class Exp. Date
Date Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
(I,sas owner of the property, or my employees with wages as their sole
cJrs pensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code).
() I am xempt ynder Section P.C. for this reason
,Date �./r [e Signature of Owner t R! f 4:
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
.Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section'need not be completed if the permit valuation is for $100.00 or less). .
( ,,.,I`Certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fo ` with comply with those provisions. f
ate: at Applicant ;%5
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall; indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
corrects I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes; /
?Signature (Owner/Agent) �J DateT
A"'
BUILDING PERMIT
PERMIT`
DATE 1/23P)6
VALUATION S7,634.00
LOT
TRACT
JOB SITE ADDRESS
7&745 iRWIN CIRCLE
APN
69id-MVI
OWNER
CONTRACTOR
OWN RJf3(ADER .
'18745 iltWIN CIR
LA QI.JINfA CA 92253
DESIGNER/ENGINEER
USE OF PERMIXDb,)RION
Coriveft thiat Car gwo t(t den/office.
t
FEE DESCRIPTION
FEES
BONUS ROOM 220.00 "li
Wrl'KATED COST OF COMM UCT 10N
7,634AH)
LAN CHUCKFEE 101-000-419-319 W-35
,
CONSTRIJCT,ION r414 ,' J0.1-000-418-000 09.00
NI+uCHANIC:AL FfT 101-000-421-0011 $15,00
11LECTICAL FRE 101.-0(20-420TM0 0 $22.70
PIXM I114Ci F FFI 101-I100-119-00()
STONO:vl:afION FFX . RhStp 100„000-24.1.000
•2
.:1
SUB-1'(�'i'AL GOND `dZi1Ci't�i:N3 AND PLAN C. ECK
$201..8:
,-LESS PRE—PAID FRES
$0.00
TOTAL Ytul Mff VC ES DUE NOW
$201.91
RECEIPT
DATE
BY
DATE FiNALED
INSPECTOR
INSPECTION RECORD .
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Back
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines -
Party Wall Firewall
Exterior Lath ,
Drywall - Int. Lath
Final
Final
BLOCKWALL PP OVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping _
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified .School District
82-879 Hiehwav 111
_
indi('A 97.2.01
Document Cannot lie Duplicatea 410_17g _'�Si;nn
Bak:
II2^/9A
No. 14078
C:E.R,m,iC;A,a; Ur' C OMPLIANC E
ADN W At►a_2 i2_W) I
Jurisdiction I.a.Ouinta.
oj,nj.r N tmp Billy J. & Leslie Seals
78745 ctr ± Irwin Cir.
i c.ity -La Ouinta Zio 92253
Pprmit #
log.#
Study Area 233
•Trnet # Lot # Souare. Footage 220
Tyne of Development Residential Addition No. of Units l
r.___�__�.. �Rnnne Rnnm a�lriitinn �
i I
At the present time, the Desert Sands Untied School District does not collect fees on
.# garages/carports, covered patios/walkways, residential additions under 500 square feet, detached
r accessory structures or replacement mohilehomes. It has been determined the above-named owner is
exempt from paving school fees at this time due to the tollowing reason:
'Residential! Addition 500 So Feet or Less
EXEMPT
This certifies that school facility fees imposed nurma.nt to Government Code 53080
in the amount of 0.00 x 220 or $0:00
the nronerty listed a:hove and that hmiding permits and/or Certificates ofOccunancv for
this square taotaee in this proposed project may now he issued- -
r •�
Hees Paid Kv N/A='fele hone1. 777_1:53Q
Name on the check
Uv Dolores A. Hailesteros
Superintendent
Fee collected /exempted by Pauline Pearson
Signature D,
Exempt $0.00
I
('".'heck No N/A
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Ongtnal- Building Det)UApplicanl UoUv Avvhcani/Recelpl Com - Account=
^ Af` `� S.�iti.�.� 1�1:,•+�,`�'w.+�S'wrerr •llV-rY TI���rn�Lr-�:rti:::'r:idi` �.�Iry"t. r..�C'(•„5-.rM' -. ,y�...�,,,.'rr. w..-......�...... w -.. .:.v:. �.-�n
ail
OWNER / BUILDER. INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may -protect yourself from possible
liability if that person applies for the proper permit in his or her name. '
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise'engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal, social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you.do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed_ contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own'work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-105 Calle Estado
La Quinta,. CA 92253
(619) 564-2246
FAX: (619) 564-5617
&I
OWNER'S SICYNATURE/DATE
-79 -7 Y � i, oll �c-�-
PROPERTY ADDRESS
PERMIT NUMBER(s)
co
C)
kv
VI
13
TIN
W 1A
Paae I OT 222) LF -1 R
tidtca;:e.ai COmEl fiance: Residential
.0 fact nue / Date
Bill + I�� SI 1 .Se, I f ��t ra e fo ���t
Budding Permit
ojeet Address ClLl
- '7 e — "77 r W 1 L+ (� 1� ? Plan Che,, r Date
ocumentation Author Telephone
Field Check i Date
-PcL c � _D-
amplianee Method (Package, Point System or Computer) Climate Zone Enforcement Agency Use Only
!ENERAL INFORMATION
otal Conditioned Floor Area: 2�o ft2
'_•uilding Type: -AZ Single Family. Addition
:heck one or more) Multi -Family Existing -Plus -Addition
=ront Orientation:North East / South / West / All Orientations
(Input onentatton in degrees and circle one.)
14umber of Dwelling Units:
=loor Construction Type: Slab Raised Floor (circle one or both)
3UILDING SHELL INSULATION
Construction
3 ponent Insulation Assembly Location/Comments
rvnP R -Value U Value (attic to garage typical. etc.)
Wall ...... :....... P-0
Wall ..............
Roof ............. -3 0
Roof .............
Floor .............
Floor .............
Slab Edge ....
IYZ kli
u,
FENESTRATION
Fenestration Area 'Fenestration
nriontntinn tcft LI -Value
Front..... ( )
Front..... ( )
Left ....... ( )
Left.......
Rear..... ( )
Rear ..... ( )
Right..... ( )
Right.....
Skylight .......
Skylight .......
Shading Devices
Interior
(roller blind. etc.
THERMAL MASS
Type/Covering Area Thickness
slab/exposed. tile. etc.) (sf) (inches
Tj Lr lf 7V
Lion 44
Review January 1992
Exterior
(shadescreen. etc.)
Overhang
Nes/nol
escription (kitchen, bath. etc.
Framing
4
i
�( Certificate of Compliance: Residential 2 of 2
(Page ) CF -1 R
prolet:t Title
Date
t
HVAC SYSTEMS
Note: Input hyc ronic or combined hydrontc data under Water Healing Systems. except Design Heating Load.
Heating Equipment Minimum str
Tle.a
Type (furnace, neat Ype.and Duct or
Efficiency Location Piping Thermostat
pump, etc.' (AFUE/HSPF) cducts/attic etc) R -Value Tvoe
Cooling Equipment Minimum Duct
Type (air conditioner, Efficiency Location
heat oumo. evao. coolina) (SEER) (attic etc )
WATER HEATING SYSTEMS
Water Heater Distribution Number nputdjkW
Type Type in System or Btu/hrt
Duct Thermostat
R -Value Tvpe
Configuration
(sDlit or oack,
Energy
External
Tank Factor or
Tank
Capacity Recovery Standby(
Insulation
(gallons) Efficiency Loss (%)
R -Value
I . For small gas storage (rated input 5 75.000 etu/hr),
For electric resistance and hes water heaters, list Energy Factor.
large gas storage water heaters (rated input a 75,000 Btu/hr), list Rated Input. Recovery Efficiency and Standby Loss.
For Instantaneous gas water heaters, list Rated Input and Recovery Efficiency.
SPECIAL FEATURES/REMARKS (Add extra sheets if necessary)
COMPLIANCE STATEMENT
This certificate of compliance lists the building features and performance specifications needed to comply with Title 24, Parts t and 6, of
the California Code of Regulations, the administrative regulations to Implement them. This certificate has been signed by the
individual with overall design. responsibility. When this certificate of compliance Is submitted for a single budding plan to be built in multiple
orientations, any shading feature that is varied is Indicated In the Special Features/ Remarks section.
Designer or Owner (per ausiness a Professions code)
Name: /fit(( SECo�s
Title/Firm: C� w ti e, a V\ 1& cv
Address: G� c1 -c
Telephone:
Lic. ear: Ow"per- Va"t&-ov
(signature)
(date)
Enforcement Agency
Name:
Tata:
Agency:
Telephone:
(Sig naare/stamp)
(date)
Documentation Author
Name:
ride/Firm:
Address:
Telephone:
.(signature) (data)